Bupa Care Services NZ Limited - Flaxmore Care Home

Bupa Care Services NZ Limited - Flaxmore Care Home

Introduction

This report records the results of aCertification Audit ofa provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008).

The audit has been conducted byHealth and Disability Auditing New Zealand Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.

The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).

You can view a full copy of the standards on the Ministry of Health’s website by clicking here.

The specifics of this audit included:

Legal entity:Bupa Care Services NZ Limited

Premises audited:Flaxmore Care Home

Services audited:Dementia care

Dates of audit:Start date: 24 July 2017End date: 25 July 2017

Proposed changes to current services (if any):None

Total beds occupied across all premises included in the audit on the first day of the audit:42

Executive summary of the audit

Introduction

This section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards:

• consumer rights
• organisational management
• continuum of service delivery (the provision of services)
• safe and appropriate environment
• restraint minimisation and safe practice
• infection prevention and control.

As well as auditors’ written summary, indicators are included that highlight the provider’s attainment against the standards in each of the outcome areas. The following table provides a key to how the indicators are arrived at.

Key to the indicators

Indicator / Description / Definition
Includes commendable elements above the required levels of performance / All standards applicable to this service fully attained with some standards exceeded
No short falls / Standards applicable to this service fully attained
Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity / Some standards applicable to this service partially attained and of low risk
A number of shortfalls that require specific action to address / Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk
Major shortfalls, significant action is needed to achieve the required levels of performance / Some standards applicable to this service unattained and of moderate or high risk

General overview of the audit

Bupa Flaxmore provides dementia level care for up to 50 residents. During the audit, there were 42 residents.

This certification audit was conducted against the relevant Health and Disability Standards and the contract with the district health board and Ministry of Health. The audit process included the review of policies and procedures, the review of residents and staff files, observations, interviews with family, management, staff and a general practitioner.

The care home manager is experienced in aged care. She is supported by a clinical manager/RN, and administrator. There is a registered nurse rostered daily.

The philosophy and strategic plans are implemented by the organisation and service that reflect a person/family-centred approach to all services.

The service has embedded interRAI into their current documentation. Formal assessments and risk assessments were in place and reflected into care plans.

The environment has been enhanced and includes brush fencing around the external garden area and the establishment of a sensory garden.

This certification audit identified that improvements are required in relation to corrective actions, staff education, medication management and maintenance.

Consumer rights

Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. / Standards applicable to this service fully attained.

The service complies with the Health and Disability Commissioner’s Code of Health and Disability Consumers’ Rights. Staff strive to ensure that care is provided that focuses on the individual resident, values residents' autonomy and maintains their privacy and choice. Cultural needs of residents are met. Policies are implemented to support residents’ rights, communication and complaints management. Information on informed consent is included in the admission agreement and discussed with residents and relatives. Care plans accommodate the choices of residents and/or their family/whānau. Complaints and concerns have been managed and a complaints register is maintained.

Organisational management

Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner. / Some standards applicable to this service partially attained and of low risk.

The care home manager is supported by an administration manager, clinical manager, registered nurses, caregivers and support staff. The quality and risk management programme includes a service philosophy, goals and a quality and risk management programme. Internal audits generate improvements in practice and service delivery. Meetings are held to discuss quality and risk management processes and results. Resident/family meetings are held and satisfaction is monitored via annual satisfaction surveys. Health and safety policies, systems and processes are implemented to manage risk. Incidents and accidents are reported and investigated. An education and training programme is implemented with a current plan in place. Appropriate employment processes are adhered to. There is a roster that provides sufficient and appropriate staff cover for the effective delivery of care and support. Privacy of health information is maintained.

Continuum of service delivery

Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. / Some standards applicable to this service partially attained and of low risk.

There is an admission package available prior to or on entry to the service, including individual information about the dementia units. Residents’ records reviewed provide evidence that the registered nurses utilise the interRAI assessment to assess, plan and evaluate care needs of the residents. Care plans are developed in consultation with the resident (where possible) and family. Care plans demonstrate service integration and are reviewed at least six-monthly. Residents’ files include three monthly reviews by the general practitioner. There is evidence of other allied health professional input into resident care.

Medication policies reflect legislative requirements and guidelines. All staff responsible for administration of medicines complete education and medicines competencies. The medicines records reviewed included documentation of allergies and sensitivities.

An activities programme is implemented that meets the needs of the residents. The programme includes community visitors and outings, entertainment and activities.

All food and baking is done on-site. Residents' nutritional needs are identified and documented. Choices are available and are provided. The organisational dietitian reviews the Bupa menu plans.

Safe and appropriate environment

Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. / Some standards applicable to this service partially attained and of low risk.

The building has a current warrant of fitness and emergency evacuation plan. Ongoing maintenance issues are addressed. Chemicals are stored safely throughout the facility. Cleaning and maintenance staff are providing appropriate services.

There is sufficient space to allow the movement of residents around the facility using mobility aids. There are a number of small lounge and dining areas throughout the facility in addition to its main communal areas. The internal areas are able to be ventilated and heated. The outdoor areas are safe and easily accessible and secure. Appropriate training, information and equipment for responding to emergencies are provided. There is an emergency management plan in place and adequate civil defence supplies in the event of an emergency. There is an approved evacuation scheme and emergency supplies for at least three days. A staff member trained in CPR and first aid is on duty at all times.

Restraint minimisation and safe practice

Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. / Standards applicable to this service fully attained.

Restraint minimisation and safe practice policies and procedures are in place. Staff are offered training in maintaining a restraint free environment and challenging behaviour management. On the day of audit there were no residents using restraint or enablers. Restraint management processes are in place should the need for restraint arise.

Infection prevention and control

Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme. / Standards applicable to this service fully attained.

The infection control programme and its content and detail are appropriate for the size, complexity and degree of risk associated with the service. The infection control coordinator (registered nurse) is responsible for coordinating/providing education and training for staff. The infection control manual outlines a comprehensive range of policies, standards and guidelines, training and education of staff and scope of the programme. The infection control coordinator uses the information obtained through surveillance to determine infection control activities, resources and education needs within the facility. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections. The service engages in benchmarking with other Bupa facilities. Staff receive ongoing training in infection control.

Summary of attainment

The following table summarises the number of standards and criteria audited and the ratings they were awarded.

Attainment Rating / Continuous Improvement
(CI) / Fully Attained
(FA) / Partially Attained Negligible Risk
(PA Negligible) / Partially Attained Low Risk
(PA Low) / Partially Attained Moderate Risk
(PA Moderate) / Partially Attained High Risk
(PA High) / Partially Attained Critical Risk
(PA Critical)
Standards / 0 / 41 / 0 / 4 / 0 / 0 / 0
Criteria / 0 / 89 / 0 / 4 / 0 / 0 / 0
Attainment Rating / Unattained Negligible Risk
(UA Negligible) / Unattained Low Risk
(UA Low) / Unattained Moderate Risk
(UA Moderate) / Unattained High Risk
(UA High) / Unattained Critical Risk
(UA Critical)
Standards / 0 / 0 / 0 / 0 / 0
Criteria / 0 / 0 / 0 / 0 / 0

Attainment against the Health and Disability Services Standards

The following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessedat every audit.

Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section.

For more information on the standards, please click here.

For more information on the different types of audits and what they cover please click here.

Standard with desired outcome / Attainment Rating / Audit Evidence
Standard 1.1.1: Consumer Rights During Service Delivery
Consumers receive services in accordance with consumer rights legislation. / FA / The Health and Disability Commissioner’s (HDC) Code of Health and Disability Consumers’ Rights (the Code) policy and procedure is implemented. Discussions with the care home manager, clinical manager/RN, administrator and care staff including three caregivers who cover all three shifts and two registered nurses (RNs), confirmed their familiarity with the Code. Interviews with six relatives confirmed that the services being provided are in line with the Code. The Code is discussed at resident/family and staff meetings.
Standard 1.1.10: Informed Consent
Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent. / FA / There are established informed consent policies/procedures and advanced directives. General consents obtained on admission were sighted in the seven residents’ files reviewed. Advanced directives if known were on the residents’ files. Copies of enduring power of attorney (EPOA) were in resident files for residents deemed incompetent to make decisions.
Resident files reviewed contained a signed admission agreement.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / There is a policy that describes the role of advocacy services. Staff receive training on advocacy services (link to 1.2.7.5). Information about accessing advocacy services is available in the information presented to residents and their families during entry to the service. Advocacy support is available if requested. Interviews with staff and relatives confirmed that they are aware of advocacy services and how to access an advocate. The complaints process reminds the complainant of their right to contact the health and disability advocacy service with contact details provided.
Standard 1.1.12: Links With Family/Whānau And Other Community Resources
Consumers are able to maintain links with their family/whānau and their community. / FA / Residents are encouraged to maintain family networks. Care staff interviewed confirmed that families are encouraged to visit residents regularly. Visiting can occur at any time. Entertainers include volunteers from the community. There are four ordained ministers from local churches who regularly visit the facility. Bi Monthly newsletter to residents and families of what’s on and what is happening. The activities plan is printed and emailed to families who are encouraged to join in
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The complaints policy describes the management of the complaints process. Complaints forms are available at reception. Information about complaints is provided on admission. Interviews with residents and families demonstrated their understanding of the complaints process. All staff interviewed were able to describe the process around reporting complaints.
There is a complaints register. Verbal and written complaints are documented. All complaints lodged had a noted investigation, timelines determined by HDC were met, and corrective actions (where indicated) were actioned. All complaints were documented as resolved.
Complaints are linked to the quality and risk management system with trends identified (if any). Discussions with residents and relatives confirmed that any issues are addressed and that they feel comfortable to bring up any concerns.
Standard 1.1.2: Consumer Rights During Service Delivery
Consumers are informed of their rights. / FA / There are posters displaying the Code. The service is able to provide information in different languages and/or in large print if requested. On entry to the service the care home manager, administrator or clinical manager discusses the Code with the resident and the family/whānau. Information is given in the information pack to the resident, next of kin or enduring power of attorney (EPOA) to read and discuss.
Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect
Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence. / FA / The service has policies which align with requirements of the Privacy Act and Health Information Privacy Code. All care staff interviewed demonstrated an understanding of privacy and could describe how choice is incorporated into residents’ cares. Family members interviewed confirmed that staff promote the residents’ independence wherever possible and that residents’ choices are encouraged. There is an abuse and neglect policy that is implemented and annual training on abuse and neglect has been provided. (link to finding 1.2.7.5).
Standard 1.1.4: Recognition Of Māori Values And Beliefs
Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs. / FA / The service has established Māori cultural policies to help meet the cultural needs of Māori residents. Bupa has developed Māori Tikanga best practice guidelines, which are posted in visible locations. The service has established links with local Māori advisors (e.g., Te Piki Oranga and Whakatohea).
Cultural training in-services take place every two years with the last in-service in 2015 and an in-service scheduled later this year (link 1.2.7.5). A cultural assessment is completed during a Māori resident’s entry to the service. There were no residents who identified as Māori.
Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs
Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs. / FA / The service has established cultural policies aimed at helping to meet the cultural needs of its residents. All families interviewed reported that they were satisfied that the residents’ cultural and individual values were being met. Information gathered during assessment including the residents’ cultural beliefs and values, is used to develop a care plan which the resident (if appropriate) and/or their family/whānau are asked to advise. Discussions with staff confirmed that they are aware of the need to respond to the cultural needs of the residents. There were no residents at the facility where English was their second language.